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Application of bone cement directly to the implant in primary total knee arthroplasty. Short-term radiological and clinical follow-up of two different cementing techniques. Arch Orthop Trauma Surg 2024; 144:333-340. [PMID: 37736767 DOI: 10.1007/s00402-023-05057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/02/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE This study aimed to optimize cement application techniques in fully cemented primary total knee arthroplasty (TKA) by comparing the effects of two different approaches: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term presence of radiolucent lines (RLL) as indicators of potential complications. METHODS In this monocentric study, a total of 379 fully cemented primary TKAs (318 patients) were included. The two study groups were differentiated by the technique of cement application: CoB group (cement applied only on bone surface) and CoBaI group (cement applied on both bone surface and implant surface). The presence of RLL or osteolysis was evaluated using the updated Knee Society Radiographic Evaluation System. RESULTS In the whole study population, RLL were present in 4.7% of cases, with a significantly higher incidence in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up, RLL were observed in 29.8% of TKAs in the CoBaI group, while the incidence was lower in the CoB group (24.0%) (not statistically significant). There were two revisions in each group, none of which were due to aseptic loosening. CONCLUSION The findings of this study suggest that the application of bone cement on bone surface only (CoB) may be more beneficial than applying it on both bone surface and implant surface (CoBaI) in terms of short-term presence of RLL in fully cemented primary TKA. Long-term results, especially with regard to aseptic loosening, will be of interest and may provide valuable guidance for future directions in bone cement applications in TKA.
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Medialized Dome and Anatomic Onlay Patella Designs in the Modern Posterior Stabilized Rotating Platform Total Knee Arthroplasty Demonstrate No Clinical or Radiological Differences at One Year. J Arthroplasty 2024; 39:87-95. [PMID: 37321517 DOI: 10.1016/j.arth.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND A successful outcome after total knee arthroplasty (TKA) includes the restoration of patellofemoral function. Modern patella component designs in TKA include a medialized dome and more recently, an anatomic design. There is a paucity of literature comparing these 2 implants. METHODS This prospective nonrandomized study examined 544 consecutive TKAs with patella resurfacing using a posterior-stabilized, rotating platform knee prothesis performed by a single surgeon. A medialized dome patella design was used in the first 323 cases and an anatomic design in the subsequent 221 cases. Patients were assessed preoperatively, at 4 weeks and 1-year post-TKA for Oxford Knee Score (OKS) (total, pain, and kneeling components) and range of movement (ROM). Radiolucent lines (RLLs), patellar tilts and displacements, as well as reoperations were assessed at 1-year post-TKA. RESULTS At 1-year post-TKA, both groups demonstrated similar improvements in ROM, OKS, pain, and kneeling scores, and had a similar incidence of fixed-flexion deformity (all P > .05). Radiographically, there was no clinically significant difference in the incidence of RLLs, patellar tilts, and displacements. The prevalence of reoperations (1.8 versus 3.2%, P = .526) was similar between the designs with no patella-related complications. CONCLUSION Both medialized dome and anatomic patella designs result in improved ROM and OKS with no patella-related complications. However, our study showed no differences between the designs at 1 year.
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How to Manage Metallosis: A Retrospective Cohort Analysis after Revision Hip Surgery. J Clin Med 2023; 12:4809. [PMID: 37510924 PMCID: PMC10381485 DOI: 10.3390/jcm12144809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Adverse local tissue reactions to metal debris are due to a metal-on-metal bearing complication caused by micromotions at modular interfaces that induce corrosion of the protective oxide layer. This process could lead to wear, fretting, and abrasion with the release of metal ions locally and systemically, which may cause adverse local reactions in nearby tissues. The aim of this study is to describe a series of patients with painful local adverse tissue reactions secondary to corrosion at the modular neck-body interface, to document the clinical presentation, diagnostic workup, and surgical findings of our research, and to search for a possible correlation between metallosis and infection. METHODS A retrospective study of patients with adverse local tissue reactions due to metal surface corrosion was performed. Blood samples were collected to identify erythrocyte sedimentation rate, C reactive protein, and procalcitonin, and a magnetic resonance imaging protocol was performed. RESULTS Serum cobalt and chromium levels of the 43 patients tested were significantly higher on average. However, both erythrocyte sedimentation rate and C-reactive protein were significantly elevated. Magnetic resonance imaging showed adverse reactions to metal debris with large soft tissue masses and surrounding tissue damage. CONCLUSIONS Corrosion in hip prosthesis can lead to the release of metal ions and debris locally and systemically, resulting in local soft tissue changes. A "tumor-like" debridement can reduce this complication.
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Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study. J Clin Med 2023; 12:4544. [PMID: 37445579 DOI: 10.3390/jcm12134544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality. METHODS We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio. RESULTS The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%. CONCLUSIONS Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.
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Total Hip Arthroplasty: So Hip It Hurts. J Clin Med 2023; 12:jcm12113849. [PMID: 37298044 DOI: 10.3390/jcm12113849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
Total hip arthroplasty (THA) has become a standard surgical intervention for patients with hip joint disorders [...].
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Patient-specific instrumentation in total knee arthroplasty: a review of the current literature. Acta Orthop Belg 2023; 89:299-306. [PMID: 37924556 DOI: 10.52628/89.2.11543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2023]
Abstract
Total knee arthroplasty (TKA) is one of the most frequently performed interventions in the field of Orthopaedic surgery. Over the last decades the implantation technique has improved continuously. The majority of patients is satisfied with the clinical outcome of TKA. However in various clinical follow-ups, up to 20% of unsatisfied patients can be observed. Periprosthetic infection and aseptic loosening seem to be the most common reasons for failure. Malalignment has been discussed as a cause of aseptic loosening and often leads to revision surgery. In order to increase the precision of implant positioning and alignment, new technologies such as patient-specific instrumentation (PSI) have been developed. Since the introduction of PSI, multiple clinical studies have been performed analyzing the clinical and radiological outcome of TKA with PSI technique. This review covers the recent literature of PSI in respect to surgical accuracy, clinical outcome, time- and cost-effectiveness.
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Evaluation of FRAX in patients with periprosthetic fractures following primary total hip and knee arthroplasty. Sci Rep 2023; 13:7145. [PMID: 37130875 PMCID: PMC10154289 DOI: 10.1038/s41598-023-34230-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 04/26/2023] [Indexed: 05/04/2023] Open
Abstract
The fracture risk assessment tool (FRAX) is a tool which calculates an individual 10-year fracture risk based on epidemiological data in patients with a risk of osteporosis. The aim of this study was to evaluate the value of FRAX to estimate the risk of postoperative periprosthetic fractures (PPF) in patients following with total hip and knee arthroplasty. 167 patients (137 periprosthetic fractures in total hip arthroplasty and 30 periprosthetic fractures in total knee arthroplasty) were included in this study. Patients' data was retrieved retrospectively. In each patient the 10-year probability of a major osteoporotic fracture (MOF) and an osteoporotic hip fracture (HF) was calculated using FRAX. According to the NOGG guideline 57% of total hip arthroplasty (THA) patients and 43.3% of total knee arthroplasty (TKA) patients were in need of osteoporosis treatment, whereas only 8% and 7% received an adequate one respectively. 56% of the patients with PPF after THA and 57% of the patients with PPF after TKA reported about a previous fracture. Significant associations between the 10-year probability of a MOF and HF calculated by FRAX and PPF in THA and TKA were seen. The results of the present study show that FRAX might have the potential to estimate the PPF in patients following THA and TKA. FRAX should be calculated before and after THA or TKA in order to assess the risk and counsel patients. The data show a clear undertreatment of patients with PPF in respect to osteoporosis.
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Arthroscopic findings and treatment of maisonneuve fracture complex. BMC Musculoskelet Disord 2021; 22:821. [PMID: 34560870 PMCID: PMC8461909 DOI: 10.1186/s12891-021-04713-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 09/11/2021] [Indexed: 02/05/2023] Open
Abstract
Background The Maisonneuve fracture complex (MFC) is a well-known lower leg injury. However, the optimal treatment is still not clear and there is limited data on concomitant injuries of cartilage. Therefore, the aim of our study was to report the incidence of incidental cartilage injuries and their management in arthroscopic treatment of MFC. Patients and methods Between February 2018 and February 2021 all patients presenting with MFC in our department were treated with diagnostic ankle arthroscopy and percutaneous syndesmotic screw or suture-endobutton fixation. In case of instable cartilage, it was debrided and according to the International Consensus Meeting on Cartilage Repair of the Ankle, in grade IV lesions < 10 mm or < 100 mm2 area the subchondral bone was microfractured. Results Eighteen patients, 16 male and two female, with a mean age of 48.1 years, were included. In all cases, instability of the distal tibiofibular articulation was confirmed arthroscopically. Injuries of the cartilage were found in 56% of the cases and in 31% of the patients surgical intervention was required. In three talar and one tibial lesion additional arthroscopic bone marrow stimulation with microfracture of the subchondral bone was performed. Conclusions Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. Due to the high rate of chondral lesions, addressing these arthroscopically may contribute to better postoperative results. Level of evidence IV
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Patient-reported outcomes after primary rotating hinge total knee arthroplasty: a multi-centre clinical cohort study. INTERNATIONAL ORTHOPAEDICS 2021; 45:2893-2897. [PMID: 34324043 DOI: 10.1007/s00264-021-05162-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Rotating hinge prostheses for total knee arthroplasty (TKA) are mostly used in revision setting; however, evidence on the use of these constrained devices in primary setting is scarce and inconsistent. Therefore, we aimed to evaluate the functional outcomes after third-generation rotating hinge implants in primary TKA with a minimal follow-up of two years in a large dual-centre observational retrospective clinical trial. METHODS The hospital databases of two centres were searched for primary rotating hinge arthroplasty from January 2007 to January 2015. A minimum follow-up of at least two years was assured. Patients meeting the inclusion criteria were asked to fill out two self-reported functional scores, the Oxford Knee Score (OKS) and Forgotten Joint Score (FJS), to measure the functional status of the knee. RESULTS In total, 267 primary rotating hinge knee arthroplasties in 242 patients were performed in two centres. The three major indications were axial malalignment (valgus/varus > 15°), 87/267 (33%), persistent ligamentous instability (28%) and neuromuscular disorders (12%). 184 patients with 202 primary rotating hinge knee arthroplasties could be included that provided data of the self-reported outcome measures (OKS and FJS). A mean OKS score of 37.71 (± 9.23) and a mean FJS score of 63.65 (± 31.01) could be obtained. CONCLUSION This large clinical study suggests that constrained devices provide the best results when treating bone-on-bone tricompartimental osteoarthritis of the knee with severe axial deviation (valgus/varus > 15°) and/or persistent ligamentous instability.
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Bone marrow aspirations in Ewing sarcomas: Are they still necessary? A single-center retrospective analysis and review of the literature. J Cancer Res Ther 2020; 16:713-717. [PMID: 32930108 DOI: 10.4103/jcrt.jcrt_941_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background and Objectives Currently, one of the most useful prognostic indicators in Ewing sarcomas (ES) is the presence of metastatic disease at diagnosis. According to various clinical guidelines, the assessment of bone marrow (BM) metastases, using light microscopy examination of bone marrow aspirates and biopsies (BMAB) is mandatory. However, the prognostic value of BM positivity is discussed controversially. Therefore, the primary aim of this study was to retrospectively review BM samples from patients with ES. Materials and Methods This retrospective single centre study included 31 patients that were newly diagnosed with ES between 2000 and 2014. Twenty-seven patients had skeletal ES and in 4 patients the tumour was localized in the soft tissue only. Metastases at diagnosis were present in 5 out of 31 patients. BM samples were morphologically and immunohistochemically searched and screened for the presence or absence of BM metastases. Furthermore, in 15 of the 31 patients BM samples were still available and were reanalysed, using nested-polymerase chain reaction. Results All BM samples of our 31 ES patients, including the 5 metastatic patients, were, morphologically and immunohistochemically tested negative for tumour cell appearance. The nested-PCR results were also negative in all of our 15 retested patients, including two patients with metastatic disease. Conclusions Based on our results and on the contradictory results reported in the literature we recommend a re-evaluation of the necessity and the prognostic value of BMAB in the initial staging process of newly diagnosed ES patients.
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Abstract
Purpose Unicompartmental knee arthroplasty (UKA) is a treatment option for anteromedial osteoarthritis of the knee. The number of UKA has been increasing constantly worldwide in recent decades. The aim of this study was to determine the most frequently cited scientific articles addressing this subject and to establish a ranking of the 50 most influential papers. Methods The 50 most cited articles related to UKA were searched in Web of Science® (Clarivate Analytics, Penn., USA) by the use of defined search terms. All types of scientific papers with reference to this topic were ranked according to the absolute number of citations and analyzed for the following characteristics: journal title, year of publication, number of citations, citation density, geographic origin, article type, and level of evidence. Results The 50 most cited articles had up to 453 citations. Most papers were published in the Journal of Bone and Joint Surgery (British volume). More than half of the articles were published in the 2000s and 2010s (n = 30). Ten countries contributed to the top 50 list, with most contributions from the UK (n = 17). Most articles could be attributed to the category of Clinical Science (n = 33), and most reported level IV studies. Conclusion Most of the frequently cited articles in UKA are clinical studies that have a low level of evidence. Few basic scientific studies could be identified, which suggests that most product development is done by commercial companies.
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Adolf Lorenz and the Lolita Armour Case. INTERNATIONAL ORTHOPAEDICS 2020; 44:1869-1874. [PMID: 32494844 PMCID: PMC7452926 DOI: 10.1007/s00264-020-04620-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
Almost 120 years ago, in 1902, the American multimillionaire J. Ogden Armour invited the Austrian orthopaedic surgeon Adolf Lorenz, professor at the University of Vienna, to treat his daughter Lolita. Lolita was born premature in 1896 and spent the first months of her life in an incubator. Later she was diagnosed with congenital dislocation of both hips. Lorenz had developed a "bloodless" treatment method and was invited by the Armour family to Chicago to "operate" on Lolita. Both hips had already been treated by an American orthopaedic surgeon before but without a satisfactory result. Lorenz should achieve a better one. The operation was performed in Chicago on 12 October 1902 and was accompanied by a very large media spectacle. This article is mainly based on contemporary newspaper reports.
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Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost. INTERNATIONAL ORTHOPAEDICS 2020; 44:1217-1221. [PMID: 32342142 PMCID: PMC7260263 DOI: 10.1007/s00264-020-04577-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
Purpose The issue of rising healthcare costs and limited resources is a topic of worldwide discussion over the last several decades. We hypothesized that failure of proximal humeral fracture osteosynthesis is presumed to be an important determinant in healthcare resources and related costs. The aim of this study was to calculate the total hospital-related healthcare cost of proximal humeral fracture osteosynthesis over one year focusing on failure. Methods A total of 121 patients with a proximal humeral fracture treated by angular stable osteosynthesis were included in this retrospective study. All hospital-related healthcare costs were investigated. Five main hospital-related cost categories were defined: hospitalization cost, honoraria, day care admission, materials, and pharmaceuticals. Results A total healthcare cost of € 1,139,448 was calculated for the whole patient group. Twelve patients needed revision surgery due to complications or fixation-related failure. This failure rate alone costed € 190,809 of the healthcare resources. In other words, failure after proximal humeral fracture osteosynthesis costed 17% of the total healthcare expenditure inone year. Conclusion This study demonstrates that a high amount of hospital-related healthcare resources is spent because of failure after proximal humeral fracture osteosynthesis. Further research is necessary and should investigate on how to prevent failure. This is not only in the patient’s interest, but it is also of great importance for maintaining a healthy healthcare system.
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Body image, self-esteem, and quality of life in patients with primary malignant bone tumors. Arch Orthop Trauma Surg 2020; 140:1-10. [PMID: 31127406 PMCID: PMC6942008 DOI: 10.1007/s00402-019-03205-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with primary malignant bone tumors are facing different challenges in their everyday lives due to improved treatment and prolonged survival. This raises the question whether and to what extent their quality of life, body image, and self-esteem is affected by their disease. The aim of this retrospective study was to analyze the quality of life, body image and self-esteem of patients with primary malignant bone tumors compared to a healthy control group. METHODS A total of 56 patients (39 male, 17 female; average age 33.8 [± 14.29] years) who were treated with either osteosarcoma or Ewing-Sarcoma at the authors' institution between Jan 1989 and May 2015 were included into the study (mean follow-up: 9.1 ± 6.6] years). The control group consisted of 58 (average age 24.4 [± 3.1] years, 31 male, 27 female) healthy medical students. Standardized questionnaires were used to assess quality of life (SF-36), body image (MBSRQ) and self-esteem (RSE-scale). Student's t test were used for statistical analysis. RESULTS Quality of life (SF-36) (in physical categories) and body image (MBSRQ) was significantly lower in patients with primary malignant bone tumors compared to healthy cohort (p < 0.001). Self-esteem was not affected i n patients and did not show any difference compared to control group (23.96 vs. 24.00). DISCUSSION Physical categories of quality of life and body image sensation of patients with primary malignant bone tumors are worse compared healthy controls. However, self-esteem does not seem to be affected by the condition and its management. Patients can be encouraged about this at the time of diagnosis of a primary malignant bone tumor.
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Differences in intraosseous and extraosseous post-chemotherapy regression of Ewing sarcomas and their influence on prognosis. Pathol Res Pract 2019; 215:152613. [DOI: 10.1016/j.prp.2019.152613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 01/05/2023]
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Fetal Rhabdomyoma of the upper Extremity in a 31-Year Old Patient: a Case Report. THE ARCHIVES OF BONE AND JOINT SURGERY 2019; 7:199-202. [PMID: 31211199 PMCID: PMC6510917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/02/2018] [Indexed: 06/09/2023]
Abstract
Fetal rhabdomyomas (RM) are extremely rare benign mesenchymal tumours that occur primarily in the head and neck. This tumour exhibits immature skeletal muscle differentiation. The patients' median age is four years and surgical resection is the recommended treatment. Fetal RM of limbs are rare and not well described in the literature and if, predominantly in form of case reports. We report the second case of a fetal RM in the upper extremity in a 31-year old male patient. One should be aware of this skeletal muscle tumour and fetal RM should be considered as a differential diagnosis to its malignant counterpart rhabdomyosarcoma.
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Abstract
INTRODUCTION Preoperative planning is an essential part of total hip arthroplasty (THA). It facilitates the surgical procedure, helps to provide the correct implant size and aims at restoring biomechanical conditions. In recent times, surgeons rely more and more on digital templating techniques. Although the conversion to picture archiving and communication system had many positive effects, there are still problems that have to be taken into consideration. OBJECTIVES The core objective was to evaluate the impact of the planners' experience on the accuracy of predicting component size in digital preoperative templating of THA. In addition, the influence of overweight and obesity (according to WHO-criteria), patient's sex and component design on the accuracy of preoperative planning have been analysed. MATERIALS AND METHODS The retrospective study included 632 consecutive patients who had primary uncemented THA. Digital templating was done using "syngo-EndoMap" software by Siemens Medical Solutions AG. Mann-Whitney U test and Kruskal-Wallis test have been used for statistical analysis. The accuracy of predicting component size has been evaluated by comparing preoperative planned sizes with implanted sizes as documented by the surgeons. The planner's experience was tested by comparing the reliability of preoperative planning done by senior surgeons or residents. The influence of BMI on predicting component size has been tested by comparing the accuracy of digital templating between different groups of BMI according to WHO-criteria. The same procedure has been done for evaluating the impact of patient´s sex and component design. RESULTS The implant size was predicted exactly in 42% for the femoral and in 37% for the acetabular component. 87% of the femoral components and 78% of the acetabular cups were accurate within one size. Digital templating of femoral implant size was significantly more reliable when done by a senior surgeon. No difference was found for the acetabular component sizes. The BMI also had an impact on estimating the correct femoral implant size. In overweight patients, planning was significantly more inaccurate than normal weight people. Differences were seen in obese patients. However, these were not significant. Accuracy of acetabular components was not affected. The design of the prostheses and the patient's sex had no influence on predicting component size. CONCLUSIONS Inexperience and overweight are factors that correlate with inaccuracy of preoperative digital templating in femoral components, whereas acetabular components seem to be independent of these factors.
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Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2018; 137-138:20-26. [PMID: 30413357 DOI: 10.1016/j.zefq.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/20/2018] [Accepted: 09/20/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system. DESIGN Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations. ELIGIBILITY CRITERIA FOR SELECTING STUDIES English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded. RESULTS 47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data. CONCLUSIONS We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.
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A novel mutation in ATRX associated with intellectual disability, syndromic features, and osteosarcoma. Pediatr Blood Cancer 2017; 64. [PMID: 28371197 DOI: 10.1002/pbc.26522] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/16/2017] [Accepted: 02/16/2017] [Indexed: 01/15/2023]
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Clinical experience with the artificial bone graft substitute Calcibon used following curettage of benign and low-grade malignant bone tumors. Sci Rep 2017; 7:1736. [PMID: 28496119 PMCID: PMC5431777 DOI: 10.1038/s41598-017-02048-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 04/05/2017] [Indexed: 12/23/2022] Open
Abstract
Artificial bone graft substitutes, such as Calcibon, are becoming increasingly interesting as they do not cause donor site morbidity which is an advantage compared to autologous bone grafts. The aim of this study was to evaluate the efficacy and potential complications associated with the use of Calcibon. Twenty-seven patients with benign and low-grade malignant bone tumors were treated with curettage and refilling of the bony cavity. Based on the radiological classification system of Neer, these lesions only comprised Grade I lesions, describing cysts that only require curettage and filling, but no additional treatment. At a mean follow up of six months we observed radiological consolidation without resorption of the bone graft substitute. These observations were also made at a mean follow-up of 13 and 32 months, respectively. According to the classification system of Goslings and Gouma we observed six surgical complications. Summing up, Calcibon seems to be a reliable bone graft substitute with low complication rates. However, delayed resorption should be expected. Calcibon seems to be an alternative to autologous bone grafts or allografts in adequate indications.
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Abstract
At the beginning of the 21st century, use of large-diameter, metal-on-metal devices was a popular procedure for hip replacement in young and physically active patients; however, within a few years, the number of revisions increased, resulting in a worldwide recall for the articular surface replacement (ASR) system. Complication rates for the ASR devices implanted at the authors' department are reported, with revision rates of 32% and 30% in the ASR XL Head and ASR Resurfacing groups, respectively. Reasons for revision surgery were serum metal ion elevation, luxation or subluxation, aseptic loosening, soft tissue compromise (adverse reactions to metal debris [ARMD]), and infection. The calculated implant survival for the ASR XL Head system and the ASR Resurfacing device (DePuy Orthopaedics Inc, Warsaw, Indiana) in the current series was 79% and 90%, respectively, at 60 months. Symptomatic patients with metal-on-metal devices, with or without elevated metal ion concentrations, should undergo cross sectional imaging to exclude ARMD. In cases of increased metal ion concentrations, local pain, or ARMD, revision surgery has to be evaluated. In the future, closer monitoring of new implants is needed to prevent high failure rates, as seen with the ASR design. Furthermore, the withdrawal of the device highlights the importance of national implant registries. [Orthopedics. 2017; 40(2):e340-e347.].
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Pathologic fracture of the distal humerus due to a textiloma. J Shoulder Elbow Surg 2016; 25:e304-8. [PMID: 27663747 DOI: 10.1016/j.jse.2016.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 07/04/2016] [Accepted: 07/19/2016] [Indexed: 02/01/2023]
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Letter Regarding "Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium Histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data". J Hand Surg Am 2015; 40:2317. [PMID: 26518325 DOI: 10.1016/j.jhsa.2015.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/06/2015] [Indexed: 02/02/2023]
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Limb salvage and functional outcomes among patients with traumatic popliteal artery injury: a review of 64 cases. Wien Klin Wochenschr 2015; 127:561-6. [DOI: 10.1007/s00508-015-0715-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/19/2015] [Indexed: 11/28/2022]
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Commentary. J Neurosci Rural Pract 2015; 6:260-1. [PMID: 25883497 PMCID: PMC4387828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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The 50 highest cited papers in hip and knee arthroplasty. J Arthroplasty 2014; 29:1878. [PMID: 24780204 DOI: 10.1016/j.arth.2014.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 03/20/2014] [Accepted: 03/21/2014] [Indexed: 02/01/2023] Open
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Quality of life after volar locked plating: a 10-year follow-up study of patients with intra-articular distal radius fractures. BMC Musculoskelet Disord 2014; 15:250. [PMID: 25059690 PMCID: PMC4113487 DOI: 10.1186/1471-2474-15-250] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/18/2014] [Indexed: 12/21/2022] Open
Abstract
Background This study aimed to present functional results and patient’s health related quality of life (HRQOL) data ten years after volar locked plate fixation (VPF) of unstable intra-articular distal radial fractures (DRF). Methods Thirty-nine patients with a mean age of sixty-one years were operatively treated with VPF after intra-articular distal radial fractures. They were evaluated two, six, and ten years postoperatively according to the Gartland and Werley score. For subjective evaluation the Short Form 36 (SF-36) and the Disability of Arm, Shoulder and Hand (DASH) questionnaires were adopted. Results Overall, wrist function did not differ significantly two, six and ten years after the operation. Over 90% patients achieved “good” or “excellent” results ten years after surgery according to the Gartland and Werley score. Ten years postoperatively the results of the SF 36 did not differ significantly from the two- and six-year follow-up. Overall findings from the SF-36 did not differ significantly from the data of Austrian and American norm populations. Only in the subscale of mental health (MH) the ten-year follow-up did show significantly poorer results (p = 0.045) compared to the Austrian norm population. The median DASH scores did not show significant differences during the ten-year follow-up period. Conclusion The ten-year results of this single-center study suggest that operative treatment of intra-articular DRF with volar locked plates is a useful and satisfactory therapy option, both in terms of function and HRQOL.
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Abstract
Few studies have been performed to analyze noise levels produced by various surgical instruments in the operating room (OR). The highest levels of noise that have been described were due to instruments used for total knee arthroplasty (TKA). These high levels of noise might be a potential health hazard for patients and medical staff. Therefore, we aimed to measure noise levels of current instruments that are widely used worldwide. During a conventional primary TKA the levels of noise in the OR were measured using a Class 1 integrating-averaging sound level meter. The highest A-weighted equivalent level was produced when using a hammer during the implantation of the femoral and tibial components with 90.2 dBA. In total surgical instruments were used for about 10% of the total time of surgery. Noise exposure due to instrument use during TKA does not seem to be a potential health hazard for medical staff or patients.
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Abstract
Background Limb amputation is often an inevitable procedure in the advanced condition of various diseases and poses a dramatic impact on a patient's life. The aim of the present study is to analyze the impact of lower-limb amputations on aesthetic factors such as body image and self-esteem as well as quality of life (QoL). Methods 298 patients (149 uni- or bilateral lower-limb amputees and 149 controls) were included in this cross-sectional study in three centers. Demographic data was collected and patients received a 118-item questionnaire including the Multidimensional Body-Self Relations Questionnaire (MBSRQ), the Rosenberg Self-esteem (RSE) scale and the SF-36 Health Survey (QoL). ANOVA and student's t-test were used for statistical analysis. Results Unilateral lower-limb amputees showed a significant lower MBSRQ score of 3.07±0.54 compared with 3.41±0.34 in controls (p<0.001) and a lower score in the RSE compared to controls (21.63±4.72 vs. 21.46±5.86). However, differences were not statistically significant (p = 0.36). Patients with phantom pain sensation had a significantly reduced RSE (p = 0.01). The SF-36 health survey was significantly lower in patients with lower-limb amputation compared to controls (42.17±14.47 vs. 64.05±12.39) (p<0.001). Conclusion This study showed that lower-limb amputations significantly influence patients' body image and QoL. Self-esteem seems to be an independent aspect, which is not affected by lower-limb amputation. However, self-esteem is influenced significantly by phantom pain sensation.
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Expression of gap junction proteins connexins 26, 30, and 43 in Dupuytren's disease. Acta Orthop 2014; 85:97-101. [PMID: 24359029 PMCID: PMC3940999 DOI: 10.3109/17453674.2013.871138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 11/02/2013] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Dupuytren's disease (DD) is a benign fibroproliferative process of the palmar aponeurosis showing similarities to wound healing. Communication of cells involved in wound healing is mediated by the composition of gap junction (GJ) proteins. We investigated the expression of 3 GJ proteins, connexins 26, 30, and 43 (Cx26, Cx30, and Cx43) in DD. PATIENTS AND METHODS Fragments of Dupuytren's tissue from 31 patients (mean age 56 (30-76) years, 24 male) were analyzed immunohistochemically and compared to control tissue for expression of the GJ proteins Cx26, Cx30, and Cx43 and also alfa-smooth muscle actin (α-SMA). RESULTS 14 of 31 samples could be attributed to the involutional phase (α-SMA positive) whereas 17 samples had to be considered cords in the residual phase (α-SMA negative). Expression of Cx26 and Cx43 was seen in 12 of the 14 samples from the involutional phase, and Cx30 was seen in 7 of these. Only 4 of the 17 samples from the residual phase showed any Cx, and there was none in the controls. INTERPRETATION The high expression of GJ proteins Cx26, Cx30, and Cx43 in α-SMA positive myofibroblast-rich nodules, which are characteristic of the active involutional phase of DD, suggests that connexins could be a novel treatment target for the treatment of DD.
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Guillaume Dupuytren: his life and surgical contributions. J Hand Surg Am 2013; 38:1994-8. [PMID: 23998192 DOI: 10.1016/j.jhsa.2013.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/10/2013] [Accepted: 07/12/2013] [Indexed: 02/02/2023]
Abstract
Guillaume Dupuytren (1777-1835) was one of the most influential surgeons of the past. He described and popularized many conditions, including Dupuytren disease, which continues to carry his name. This article reviews Guillaume Dupuytren's life and his contributions in surgery.
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Abstract
BACKGROUND AND PURPOSE Dupuytren's disease (DD) is a benign fibroproliferative process that affects the palmar fascia. The pathology of DD shows similarities with wound healing and tumor growth; hypoxia and angiogenesis play important roles in both. We investigated the role of angiogenic proteins in DD. PATIENTS AND METHODS The expression of vascular endothelial growth factor (VEGF), its receptors vascular endothelial growth factor receptor 1 (VEGFR1) and vascular endothelial growth factor receptor 2 (VEGFR2), hypoxia-inducible factor alfa (HIF-1α), and alfa-smooth muscle actin (α-SMA) were analyzed immunohistochemically in fragments of excised Dupuytren's tissue from 32 patients. We compared these values to values for expression in a control group. RESULTS 15 of 32 samples could be attributed to the involutional phase (α-SMA positive), whereas 17 samples were considered to be cords at the residual phase (α-SMA negative). In the involutional phase, the HIF-1α and VEGFR2 expression was statistically significantly higher than in the residual phase and in the controls. INTERPRETATION Both the VEGFR2 receptor and HIF-1α were expressed in α-SMA positive myofibroblast-rich nodules with characteristics of DD in the active involutional phase. Thus, hypoxia and (subsequently) angiogenesis may have a role in the pathophysiology of DD.
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[Collagenase Clostridum histolyticum in the management of Dupuytren's contracture]. HANDCHIR MIKROCHIR P 2011; 43:269-74. [PMID: 21935843 DOI: 10.1055/s-0031-1286314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Dupuytren's contracture is a fibroproliferate disease of the palmar aponeurosis with a formation of nodules and cords. Surgical treatment is the gold standard for Dupuytren's contracture at the moment. A short while ago Collagenase clostridium histolyticum was licensed as a non-surgical method to treat Dupuytren's contracture. Collagenase clostridium histolyticum is injected directly into the Dupuytren's cord and after 24 h the contracture is distended by manual rupturing. Collagenase clostridium histolyticum causes a depletion of collagen, however neurovascular structures are spared. 2 clinical phase III studies showed that contractures could be effectively reduced when using Collagenase clostridium histolyticum. However, there are no long-term results regarding effectiveness and side effects, or comparative studies using surgical methods. This paper presents a review of Collagenase clostridium histolyticum and its role in the management of Dupuytren's contracture. Indication, technical procedure, treatment results and complications are described.
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Parathyroid hormone 1-84 accelerates fracture-healing in pubic bones of elderly osteoporotic women. J Bone Joint Surg Am 2011; 93:1583-7. [PMID: 21915572 DOI: 10.2106/jbjs.j.01379] [Citation(s) in RCA: 215] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Parathyroid hormone (PTH) has been shown to increase bone mineral density and to reduce the rate of fractures in patients with osteoporosis and also to improve fracture-healing. The purpose of the present prospective, randomized, controlled study was to evaluate the effect of PTH 1-84 on the course of pelvic fracture-healing and functional outcome in postmenopausal women. METHODS Sixty-five patients had a dual x-ray absorptiometry scan, radiographs, and a computed tomography scan to document pelvic fractures. Twenty-one patients received a once-daily injection of 100 µg of PTH 1-84 starting within two days after admission to the hospital, and forty-four patients served as the control group. All patients received 1000 mg of calcium and 800 IU of vitamin D. Computed tomography scans were repeated every fourth week until radiographic evidence of cortical bridging at the fracture site was confirmed. Functional outcome was assessed with use of a visual analog scale for pain and a Timed "Up and Go" test. RESULTS The mean time to fracture healing was 7.8 weeks for the treatment group, compared with 12.6 weeks for the control group (p < 0.001). At eight weeks, all fractures in the treatment group were healed and four fractures in the control group were healed (healing rate, 100% compared with 9.1%; p < 0.001). Both the visual analog scale score for pain and the result of the Timed "Up and Go" test improved in the study group as compared with the control group (p < 0.001). CONCLUSIONS In elderly patients with osteoporosis, PTH 1-84 accelerates fracture-healing in pelvic fractures and improves functional outcome.
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Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med 2009; 361:2579; author reply 2579-80. [PMID: 20050321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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39
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Medical bibliographic databases. Assoc Med J 2008. [DOI: 10.1136/sbmj.0810366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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A wheelchair using neurosurgeon. Assoc Med J 2007. [DOI: 10.1136/sbmj.0711410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hip protectors and prevention of hip fractures in older persons. Geriatrics (Basel) 2007; 62:15-20. [PMID: 17668960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Hip fractures are a worldwide problem with consequences for the health care system as well as for the individual patient. Falls in the presence of osteoporosis are the main reason for these fractures. The effectiveness of hip protectors in preventing hip fractures has been proven in several biomechanical studies; however, adherence is low. Therefore clinical studies reveal conflicting results. In order to increase adherence, it is necessary to educate older persons who are at risk on the dangers of hip fractures and the value of hip protectors as a preventive device. The design and wearing comfort of hip protectors are also important factors in adherence. Hip protectors with a more patient-friendly design are now available, and new studies should help clarify relevant issues.
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Reproductive factors and lower extremity arterial occlusive disease in women. Eur J Epidemiol 2007; 22:505-11. [PMID: 17636415 DOI: 10.1007/s10654-007-9156-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 01/23/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reproductive variables affecting sexual hormone levels seem to be significant for atherosclerosis, a major cause of morbidity of the vessels of the lower extremities such as lower extremity arterial occlusive disease (LEAOD). We quantify a direct relationship between reproductive variables including age at regular and premature menopause and the incidence of severe LEAOD among post-menopausal women. METHODS AND RESULTS Questionnaires were administered to 269 female amputees with LEAOD, 224 patients who underwent total joint replacement due to osteoarthritis and 88 healthy women. Respondents provided information on: age at menarche, age at the onset of menopause, number of births, number of abortions, lifetime oral contraceptive use, hysterectomy, oophorectomy, and medical consultation and treatment for post-menopausal symptoms. The in-sample log-odds ratio of LEAOD incidence was modeled as a function of the reproductive variables. An increase in the risk of LEAOD was associated with a reduction in the length of the fertile period, an increase in the number of births, and lifetime oral contraceptive use of 10 years or longer; a decrease in the risk of LEAOD was associated with an increase in the number of abortions. CONCLUSION We established a distinct relationship between reproductive variables, such as length of fertile period and age at menopause, and the development of severe LEAOD. The relations that we found are, by and large, consistent with other findings on similar ailments.
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Student conferences. Assoc Med J 2007. [DOI: 10.1136/sbmj.0705210a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Design: a neglected factor in medicine. Mcgill J Med 2007; 10:3. [PMID: 18523599 PMCID: PMC2323546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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